April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Volume 142, Number 5 • Progressive Hemifacial Atrophy Treatment

determining the amount of flap bulk to place in different areas intraoperatively (Fig. 1). Microvascular Operations Simultaneous flap harvest and recipient-site dissection was performed. Limited preauricular face-lift incisions from the top of the ear to the earlobe combined with a short lateral upper eye- lid incision were used for facial dissection because of inconspicuous scar and adequate exposure in patients who had a palpable superficial temporal pulse. When the superficial temporal  artery was ligated during prior reconstructive procedures, a short transverse neck incision was used to dissect branches of the external carotid artery and inter- nal jugular vein for anastomoses. Dissection of the recipient site continued at least 1 cm beyond the preoperative markings in a supra–superficial mus- culoaponeurotic system plane to allow interdigita- tion of flap tissues with uninvolved facial tissues. A modified parascapular flap based on the cir- cumflex scapular artery was primarily used. Flap design captured the circumflex scapular vascular pedicle and extended upward or in most cases curvilinearly under the arm. The orientation and width of the skin island taken was determined by the assessed tissue needs based on the preopera- tive markings. This resulted in few patients with full-thickness flap tissue (i.e., dermis, fat, and fas- cia) requirements greater than 8 to 9 cm in width. Wider tissue requirements were managed with larger extensions of dorsal thoracic fascia incor- porating overlying subcutaneous fat. Tension- free closure of the back donor site is the norm. In patients requiring greater skin, fat, and fascial composite widths, prior tissue expansion of the back cephalad and caudal to the donor site to allow primary closure was performed in two cases. Microvascular anastomoses were completed to the recipient vessels (i.e., superficial temporal or, if not available, facial vessels). Contour, depth, and size were verified before flap inset, with the flap’s deep surface and the pedicle oriented away from the skin toward the deep facial tissue (Fig. 2). Near the anastomosis, the flap may be secured with absorbable sutures to prevent tension or compres- sion of the vessels. The deep fascia of the flap was suspended to the lateral orbital rim and zygoma with buried nylon sutures, which we believe helps to minimize descent. Flaps were contoured based on the preoperative topographic markings. The skin can be totally removed down to fat to allow for greater distensibility of the subcutaneous tis- sue, which allows the flap to spread out beyond its original dimensions. Maintaining a portion of the

Fig. 2. The flap is trimmed and shaped to address the contour and soft-tissue requirements of each patient.

Fig. 3. The flap is inset beneath the facial skin.

Fig. 4. The flap is secured in place with 4-0 nylon and Xeroform (Covidien, Mansfield, Mass.) bolsters.

dermis may minimize the subsequent flap descent. Final inset (Fig. 3) and contouring with the flap in place is aided by parachuting horizontal mattress

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